Kemoembolization involves injecting specific substances into the arteries that nourish cancerous tissue. Among these substances are chemotherapy drugs and particles that restrict the supply of oxygen and nutrients. This method, which is particularly preferred for patients with liver cancer, aims to prevent tumor growth. It also plays an important role in controlling metastasized cancers.

Prof. Dr. Özgür KILIÇKESMEZ

Interventional Radiology / Interventional Neuroradiology

Prof. Dr. Kılıçkesmez holds the Turkish Radiology Competency Certificate, the Turkish Interventional Radiology Competency Certificate, Stroke Treatment Certification, and the European Board of Interventional Radiology (EBIR). In his academic career, he won the Siemens Radiology First Prize in 2008.  He provides treatments at Medicana Ataköy hospital.

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What is Kemoembolization?

Kemoembolization provides localized treatment for cancer cells. The procedure involves directly delivering drugs to the arteries feeding the tumor. In this technique, chemotherapeutic agents and particles that restrict the tumor’s blood supply are delivered via the bloodstream. This method, which began to be used in the 1970s, is particularly applied for liver cancers.
Tedavi edilen kanser türleri şunlardır:

• Hepatocellular carcinoma
• Metastatic colon cancer
• Metastatic breast cancer
• Carcinoid tumors
• Soft tissue sarcomas
• Melanoma

With this method, drugs reach the cancerous area at a higher concentration while minimizing the impact on healthy tissues. The treatment not only provides localized effects but also slows or stops tumor growth by cutting off its blood supply.

Anatomy of the Liver and Its Blood Supply

The liver is notable for its complex structure and multiple blood supply channels. The organ is divided into various lobes and segments. This segmentation plays a critical role in understanding the functional integrity of the liver. The most widely accepted classification is made by Couinaud. This system separates the liver’s sections according to the portal venous and systemic venous drainage pathways. The arterial blood flow is more variable and, in most cases, is provided through the hepatic arteries that branch from the celiac artery. These arteries branch out to supply the right and left lobes of the liver.

During kemoembolization for liver tumors, the following potential accessory arteries should be considered:

• Right phrenic artery
• Modified or accessory left hepatic artery
• Right internal mammary artery

On the other hand, to reduce the risk of unwanted kemoembolization, it is important to be aware of the following arteries:

• Cystic artery
• Right gastric artery
• Falciform artery
• Duodenal artery

Timing of the Kemoembolization Procedure

Kemoembolization is an important treatment option, especially for patients with hepatocellular carcinoma (HCC) and metastatic liver disease. This treatment is applied according to the patient’s condition and certain criteria.

Patient Evaluation and Selection

Before performing kemoembolization, the patient’s condition is carefully evaluated. According to the candidate criteria determined by the NCCN guidelines, these are:

• If the patient is not suitable for surgical intervention or is not resilient enough for surgical procedures,
• If factors such as liver function, tumor size, and number indicate that surgery is not suitable,
• If the overall health and quality of life are at a level that can sufficiently withstand the potential side effects of kemoembolization.

Ideal Candidates for Kemoembolization

Patients who are candidates for kemoembolization treatment generally have the following characteristics:

• Those with liver function classified as Child-Pugh score A or B,
• Those with an ECOG Performance Status score of 0 or 1,
• Those who, despite active tumor growth, do not show extrahepatic metastases.

Timing of Kemoembolization

Kemoembolization is recommended in the following situations:

• When patients are evaluated as a bridge therapy; this aims to reduce the tumor load before transplantation.
• When patients are being made eligible for transplantation; efforts are made to adjust tumor sizes to meet the Milan criteria.
• When there are multiple nodules and large tumors and other treatment options have proven inadequate.

Role of TAKE

Transarterial chemoembolization (TAKE) is a method particularly used for HCC and cancers that have metastasized to the liver. The goal of kemoembolization is to reduce tumor size and, if possible, make patients suitable for surgery. However, this treatment does not have a curative effect and is generally considered a palliative approach.

TACE is generally used as a first-line treatment in the following cases:

• When the patient’s liver function is stable (Child-Pugh class A or B),
• When the overall health condition is relatively good (ECOG PS 0 or 1),
• As an alternative to surgical intervention, transplantation, or other invasive treatments.

Kemoembolization has the potential to slow the progression of liver cancer and improve the patient’s survival and quality of life. The treatment is tailored to the patient’s current health condition and the stage of their cancer and is carried out by a multidisciplinary team.

Kemoembolization: Situations Where It Should Not Be Applied

Kemoembolization may not be suitable for patients with certain health issues. Although this treatment method intervenes with direct drug injection into cancer cells, in some cases, the risks may outweigh the benefits. Here are the situations in which kemoembolization should not be performed:

• It is not recommended for patients with a low expected life expectancy, especially those who are completely dependent on care.
• It is not suitable for patients with contraindications to chemotherapy such as heart or kidney failure and leukopenia.
• Kemoembolization is not recommended if the patient is not expected to comply with the treatment.
• Metastases with extrahepatic spread limit the efficacy of this treatment method.
• If the patient’s liver functions are initially weak or if there are severe liver problems such as end-stage cirrhosis, the treatment may be risky.
• Kemoembolization should not be performed in patients who show symptoms such as encephalopathy, jaundice, or those with active alcohol consumption.

In addition, certain technical difficulties may necessitate avoiding kemoembolization:

• In patients with high main portal vein thrombosis, the risk of post-procedure liver failure increases.
• Segmental injections cannot be performed in patients with bile duct obstruction or bilirubin levels above 3 mg/dL.
• If there are large tumors affecting more than half of the liver during kemoembolization, it is inadvisable to apply this treatment.

Kemoembolization may pose risks for patients with specific health conditions. Therefore, a detailed evaluation of the patient’s condition is essential before starting the treatment. It is also important to review alternative methods before applying the treatment.

Equipment Used in Kemoembolization

The kemoembolization process is carried out using specially selected materials. In this method, the basic equipment can be examined under two main categories: drug-eluting embolization particles and conventional embolization particles. The first category, drug-eluting embolization particles, are resin beads that provide slow drug release in cancer treatment. These beads carry chemotherapy drugs directly to the tumor site, offering an effective treatment.

Drug-eluting beads:

• Doxorubicin: Used for hypervascular primary hepatic tumors and metastases.
• Irinotecan: Used for treating colorectal cancer metastases.

The second category is conventional TACE. This method uses a mixture that contains lipiodol, chemotherapy drug, and an embolization agent. Both techniques intervene directly in cancerous tissues to help control the progression of the disease.

What Are the Preparations Before Kemoembolization?

Preparation for the kemoembolization process is vital for the success of the treatment. First, detailed imaging procedures of the patient are performed. Through these procedures, doctors create a detailed map of the area to be treated. Cross-sectional imaging, particularly using contrast-enhanced CT or MRI, is performed. These imaging studies provide critical information such as the location and size of the tumor. Additionally, during this process, other important vascular structures in the liver and possible abnormalities are identified.

During treatment planning, radiologists use special techniques to identify the main arteries that feed the tumor. With these techniques, accidental non-target embolization can be prevented. Correct identification and marking of the arteries help reduce potential complications during the procedure.

In terms of biomedical requirements, a biopsy may not be necessary in some cases. However, if there are suspicious conditions and the tumor does not meet the HCC criteria, a biopsy is recommended according to the NCCN guidelines. This is particularly valid for lesions that, based on imaging findings, are suspected of malignancy and do not contain risk factors.

Another important aspect to consider during the preparation process is anesthesia management. TACE procedures are generally performed under conscious sedation. The patient’s suitability for anesthesia is evaluated using the ASA physical classification system and the Mallampati score. For high-risk patients, consultation with an anesthesia specialist and, if necessary, a cardiologist is recommended.

Hydration is another critical aspect of the treatment process. Radiologists usually use an intravenous saline solution to ensure the patient is adequately hydrated before and after the procedure.

Infection prevention measures are also of great importance. Given the potential for the formation of a necrotic tissue bed and the potential for these tissues to develop into an abscess, prophylactic antibiotic treatment is a standard practice. This treatment is carried out using broad-spectrum antibiotics.

To prevent bleeding complications, certain precautions are taken:

• Laboratory tests are performed.
• The dosage of anticoagulant drugs is adjusted.

Other symptom control methods include:

• Antiemetics and steroids are administered before the procedure or when necessary.
• Octreotide may be applied before or during the procedure for patients undergoing carcinoid tumor treatment.

This preparation process is essential to ensure that kemoembolization is applied safely and effectively.

Technical Aspects of Kemoembolization

During the kemoembolization procedure, the use of an arterial catheter is fundamental. First, the arteries that supply blood to the tumor are identified and accessed via these arteries using the catheter. Microcatheter technology is utilized to reach the arteries feeding the tumor. At this stage, fluoroscopy is used to examine in detail the tumor’s blood supply. Special particles, contrast agents, and chemotherapeutic agents are used for the embolization process. The procedure continues until the arterial flow stops. A follow-up arteriography is performed after the procedure to check the status of the embolized area. This step is critical in assessing whether the embolization was effective. The presence of tumors in the liver determines the amount of chemotherapy to be administered. Important points to consider in the procedure:

• Identification and access of the arteries
• Use of a microcatheter
• Application of embolization particles and chemotherapeutic agents
• Control with follow-up arteriography

Important Issues Encountered in Kemoembolization Treatment

The kemoembolization procedure can lead to serious health issues in approximately 5 to 10 out of every 100 patients. After this treatment, patients may encounter some major complications. One of the most frequently observed complications is liver failure. Additionally, there can be unfortunate cases of patient death. Moreover, abscess formation in the abdomen may also be observed.

• Tumor rupture
• Cholecystitis
• Biloma
• Permanent bile duct stricture
• Arterial dissection
• Pulmonary embolism

Other serious issues include tissue damage due to non-target embolization and gastrointestinal bleeding. Such complications increase the risks of the treatment and may require additional therapy for the patient.

Critical Role in Treatment

This method is especially used in advanced-stage patients and directly intervenes in the arteries feeding the tumor. During the procedure, chemotherapy drugs and particles that prevent tumor growth are injected into the liver’s blood vessels. This treatment can lead to a reduction or even necrosis of the tumor, potentially prolonging the patient’s survival.

The efficacy of kemoembolization depends on various factors:

• The patient’s overall health condition
• The level of liver functions
• The size and extent of the tumor

These factors directly affect the outcome of the treatment and the treatment plan is customized for each patient. Kemoembolization is generally preferred for patients who do not respond to other treatment methods or are not suitable for surgical intervention. This method is particularly applied in the following situations:

• Patients with a high tumor load
• Cases where surgical intervention or organ transplantation is not possible

The main factors that enhance treatment success are:

• Low tumor load
• Well-preserved liver functions

Studies on treatment outcomes have shown that kemoembolization can significantly prolong survival times. Interventions in patients with liver cancer, in particular, can markedly improve survival times. However, the repetition of the treatment should be adjusted according to the patient’s condition.

Alternatives to kemoembolization vary depending on the patient’s condition and the characteristics of the tumor. Generally, the following methods are preferred:

• Intravenous chemotherapy
• External beam radiation therapy
• Tumor ablation methods:
• Thermal (microwaves or radio waves)
• Cryoablation (freezing)
• Arterial embolization of the tumor:
• Using inert particles (bland embolization)
• Using radioactive particles (radioembolization)

Improving Survival Outcomes with the Treatment Team

Hepatic kemoembolization is a process that requires collaboration between oncology and radiology specialists. The team applying this treatment develops patient-specific solutions. Post-procedure patient follow-up is particularly managed by the oncology nurse and primary caregiver. This follow-up is critical for the early detection of potential complications. Factors that affect long-term survival rates include:

• The patient’s overall health condition,
• The size and extent of the tumor,
• The comprehensiveness of the treatment methods applied.

Clinical studies have shown that TAKE (Transarterial Chemoembolization) provides better survival rates compared to supportive care methods. However, combining TACE with systemic therapies has not provided the expected benefits. In particular, the effect of the Y90 radioembolization method on patients with locally advanced or inoperable conditions has resulted in outcomes similar to monotherapy. These findings require careful consideration when evaluating the efficacy of treatment options.

Kemoembolization (TAKE) Prices 2025[/h2] The price of kemoembolization varies depending on many different factors. The type of hospital or clinic chosen is generally one of the most important factors affecting the cost. Additionally, the experience and expertise of the doctor performing the procedure can also be decisive on the fees. The quality of the chemotherapy drugs and embolization materials used can increase the total cost of the treatment. The patient’s health condition and the characteristics of the tumor also play a role in the pricing. Finally, additional services such as pre- and post-procedure tests and the duration of the hospital stay can increase the cost.

Frequently Asked Questions

Additional Resources and Documents

https://ozgurkilickesmez.com/wp-content/uploads/2024/07/Intra-arterial-therapies-for-metastatic-colorectal-cancer.pdf

https://ozgurkilickesmez.com/wp-content/uploads/2024/07/Local-and-Regional-Therapies-for-Hepatocellular-Carcinoma-and-Future-Combinations.pdf

https://ozgurkilickesmez.com/wp-content/uploads/2024/07/Transarterial-chemoembolization.pdf

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.